Szablon 2.16.840.1.113883.3.4424.13.10.1.27

Szablon [1] Realizacja recepty

ID 2.16.840.1.113883.3.4424.13.10.1.27 Data obowiązywania obowiązuje od 2019‑09‑30

Status Active Etykieta wersji 1.3.1.2

Nazwa plCdaDrugDispense Nazwa wyświetlana [1] Realizacja recepty

Opis Szablon CDA dokumentu realizacji recepty

Kontekst Nazwa ścieżki /

Typ CDA Document Level Template

Otwarty/Zamknięty Otwarty (pozostałe elementy poza zdefiniowanymi są dozwolone)

Używane przez / Używa

Używane przez Szablony 1 transakcji i 0, Używa 8 szablonów

Używane przez	jako	Nazwa	Wersja
plcda-transaction-50	Transakcja	Realizacja recepty	2017‑04‑26
Używa	jako	Nazwa	Wersja
2.16.840.1.113883.3.4424.13.10.2.88	Zawierać	[2] Dane pacjenta dla dokumentu realizacji recepty (1.3.1)	DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.84	Zawierać	[2] Autor dokumentu realizacji recepty (1.3.1.2)	DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.20	Zawierać	[2] Organizacja odpowiedzialna za dokument dla P1 (1.3)	DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.61	Zawierać	[2] Odbiorca informacji (bazowy) (1.3.1)	DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.6	Zawierać	[2] Wystawca dokumentu (bazowy) (1.3)	DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.53	Zawierać	[2] Dane zlecenia (bazowy) (1.3)	DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.83	Zawierać	[2] Dokument powiązany dla dokumentu recepty (1.3)	DYNAMICZNE
2.16.840.1.113883.3.4424.13.10.2.80	Zawierać	[2] Treść dokumentu realizacji recepty (1.3.1.1)	DYNAMICZNE

Relacje Specialization: szablon 1.3.6.1.4.1.19376.1.9.1.1.3 (2016‑01‑08 11:13:04)

Przykład

<ClinicalDocument xsi:type="extPL:ClinicalDocument">  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.9.1.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.27" extension="1.3.1"/> <id extension="1234567" root="2.16.840.1.113883.3.4424.2.7.99999.5.1" displayable="true"/> <code code="60593-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication dispensed extended"> <translation code="04.12" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Realizacja recepty elektronicznej"> <qualifier> <name code="KDLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Kategoria dostępności leku"/> <value code="Rp" codeSystem="2.16.840.1.113883.3.4424.11.1.25"/> </qualifier> <qualifier> <name code="RLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj leku"/> <value code="G" displayName="Lek gotowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wystawienia recepty"/> <value code="F" displayName="Farmaceutyczna" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb realizacji recepty"/> <value code="Z" displayName="Zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="RRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj realizacji recepty"/> <value code="Z" displayName="zamykająca" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="PREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Postać recepty"/> <value code="E" displayName="elektroniczna" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wydania leku"/> <value code="Z" displayName="zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> </translation> </code> <title>Realizacja recepty elektronicznej</title> <effectiveTime value="20150301122300"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="654321" root="2.16.840.1.113883.3.4424.2.7.99999.5.2"/> <versionNumber value="2"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.88"/> <patientRole> <id extension="1234567" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/> <id extension="96013002256" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <addr> <country>Polska</country> <postalCode>58-200</postalCode> <city>Dzierżoniów</city> <streetName>Szpitalna</streetName> <houseNumber>3a</houseNumber> <unitID>10</unitID> </addr> <patient> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <given>Anna</given> <given>Maria</given> <family>Nowak</family> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/> <birthTime value="19960130"/> </patient> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.84"/> <functionCode code="FARM" codeSystem="2.16.840.1.113883.3.4424.11.3.18" codeSystemName="ZAWODY_MED" displayName="Farmaceuta"/> <time value="20150301122300"/> <assignedAuthor> <id extension="712178" root="2.16.840.1.113883.3.4424.1.6.1" displayable="true"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>mgr</prefix> <given>Miłosz</given> <family>Najman</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.31"/> <id extension="12003" root="2.16.840.1.113883.3.4424.2.6"/> <name>Apteka porcelanowa</name> <telecom use="PUB" value="tel:32123456"/> <addr> <country>Polska</country> <postalCode>31-867</postalCode> <city>Kraków</city> <streetName>Mikołaja Kopernika</streetName> <houseNumber>36</houseNumber> </addr> </representedOrganization> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.3.4424" assigningAuthorityName="CSIOZ" displayable="false"/> </representedCustodianOrganization> </assignedCustodian> </custodian> <legalAuthenticator> <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/> <time value="20150301122300"/> <signatureCode code="S"/> <assignedEntity> <id extension="712178" root="2.16.840.1.113883.3.4424.1.6.1" displayable="false"/> </assignedEntity> </legalAuthenticator> <relatedDocument typeCode="RPLC"> <templateId root="2.16.840.1.113883.3.4424.13.10.2.83"/> <parentDocument classCode="DOCCLIN" moodCode="EVN"> <id extension="3434344" root="2.16.840.1.113883.3.4424.2.7.99999.5.1" displayable="true"/> <code code="60593-1" codeSystem="2.16.840.1.113883.6.1"/> <setId extension="654321" root="2.16.840.1.113883.3.4424.2.7.99999.5.2"/> <versionNumber value="1"/> </parentDocument> </relatedDocument> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.80"/> <structuredBody> <component> <section> <templateId root="1.3.6.1.4.1.19376.1.9.1.2.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.3.70"/> <id extension="4334343" root="2.16.840.1.113883.3.4424.2.7.99999.5.3"/> <code code="60590-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Dispensation"/> <title>Wydanie leku</title> <text> <paragraph ID="SPLY_1"> <caption>Wydano lek gotowy</caption> Nazwa: Enarenal <br/> Postać: tabletki <br/> Dawka: 5mg <br/> Opakowanie: 60 tabl. <br/> Ilość: 1 <br/> Nr serii: 123/456 <br/> Data ważności: 1 stycznia 2018 r. <br/> Identyfikator produktu: 5909990014958 (GS1/EAN) </paragraph> <paragraph ID="ACT_1"> <caption>Taksacja:</caption> Wartość wydanego leku: 12,00 <br/> Limit urzędowy: 8,40 <br/> Poziom odpłatności leku refundowanego: 100% <br/> Kwota refundacji: 0,00 <br/> Zapłacono: 12,00 </paragraph> </text> <entry> <supply classCode="SPLY" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.4"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.3"/> <templateId root="2.16.840.1.113883.10.20.1.34"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.62"/> <id extension="1234567" root="2.16.840.1.113883.3.4424.2.7.99999.5.1"/> <text> <reference value="#SPLY_1"/> </text> <effectiveTime value="20150228"/> <quantity value="1"/> <product> <manufacturedProduct> <manufacturedMaterial> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.54"/> <code code="4321" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Enarenal 5mg tabl."/> <name>Enarenal 5mg tabletki</name> <lotNumberText>123/456</lotNumberText> <pharm:expirationTime value="20180101"/> <pharm:asContent classCode="CONT"> <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE"> <pharm:code code="5909990014958" codeSystem="1.3.160" codeSystemName="GS1"/> <pharm:name>Enarenal 5mg (60 tabl.)</pharm:name> <pharm:formCode code="30066000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Tablet container"/> <pharm:capacityQuantity value="60"/> </pharm:containerPackagedMedicine> </pharm:asContent> </manufacturedMaterial> </manufacturedProduct> </product> <entryRelationship typeCode="REFR"> <substanceAdministration classCode="SBADM" moodCode="INT"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.11"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.63"/> <id extension="334455-1" root="2.16.840.1.113883.3.4424.2.7.99999.2.3"/> <code code="PREItem" codeSystem="1.3.6.1.4.1.19376.1.9.2.2"/> <consumable> <manufacturedProduct> <manufacturedMaterial nullFlavor="NA"/> </manufacturedProduct> </consumable> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.77"/> <id extension="0700000000123456654321" root="2.16.840.1.113883.3.4424.8.10.1"/> <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document"/> </externalDocument> </reference> </substanceAdministration> </entryRelationship> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.67"/> <code code="TAKSL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Taksacja leku"/> <text> <reference value="#ACT_1"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="WWL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Wartość wydanego leku"/> <statusCode code="completed"/> <value xsi:type="REAL" value="12.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="LIMU" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Limit urzędowy"/> <statusCode code="completed"/> <value xsi:type="REAL" value="8.40"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="RLPO" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Poziomy odpłatności leków refundowanych"/> <statusCode code="completed"/> <value xsi:type="CV" code="100%" codeSystem="2.16.840.1.113883.3.4424.11.1.1"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="INT"> <code code="KREF" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Kwota refundacji"/> <statusCode code="completed"/> <value xsi:type="REAL" value="0.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <code code="ZAPL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Zapłacono"/> <statusCode code="completed"/> <value xsi:type="REAL" value="12.00"/> </observation> </entryRelationship> </act> </entryRelationship> </supply> </entry> </section> </component> <component> <section> <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/> <text> <paragraph> <caption>Powód wydania leku</caption> Zagrożenie życia </paragraph> </text> </section> </component> </structuredBody> </component></ClinicalDocument>

Przykład

<ClinicalDocument xsi:type="extPL:ClinicalDocument">  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.9.1.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.27" extension="1.3.1"/> <id extension="543223454" root="2.16.840.1.113883.3.4424.2.7.99999.5.1" displayable="true"/> <code code="60593-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication dispensed extended"> <translation code="04.13" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Realizacja recepty papierowej"> <qualifier> <name code="KDLEK" codeSystem="2. 16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Kategoria dostępności leku"/> <value code="Lz" codeSystem="2.16.840.1.113883.3.4424.11.1.25"/> </qualifier> <qualifier> <name code="RLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj leku"/> <value code="G" displayName="Lek gotowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wystawienia recepty"/> <value code="Z" displayName="Zwykła" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb realizacji recepty"/> <value code="I" displayName="Import docelowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="RRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj realizacji recepty"/> <value code="Z" displayName="zamykająca" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="PREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Postać recepty"/> <value code="P" displayName="papierowa" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="RRECP" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj recepty papierowej"/> <value code="ZW" displayName="zwykła" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wydania leku"/> <value code="Z" displayName="zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> </translation> </code> <title>Realizacja recepty papierowej</title> <effectiveTime value="20150301122300"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="24543234" root="2.16.840.1.113883.3.4424.2.7.99999.5.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.88"/> <patientRole> <id extension="1234567" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/> <id extension="96013002256" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <addr> <country>Polska</country> <postalCode>58-200</postalCode> <city>Dzierżoniów</city> <streetName>Szpitalna</streetName> <houseNumber>3a</houseNumber> <unitID>10</unitID> </addr> <patient> <name> <given>Anna</given> <given>Maria</given> <family>Nowak</family> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/> <birthTime value="19960130"/> </patient> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.84"/> <functionCode code="FARM" codeSystem="2.16.840.1.113883.3.4424.11.3.18" codeSystemName="ZAWODY_MED" displayName="Farmaceuta"/> <time value="20150301122300"/> <assignedAuthor> <id extension="712178" root="2.16.840.1.113883.3.4424.1.6.1" displayable="true"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>mgr</prefix> <given>Miłosz</given> <family>Najman</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.31"/> <id extension="12003" root="2.16.840.1.113883.3.4424.2.6"/> <name>Apteka porcelanowa</name> <telecom use="PUB" value="tel:32123456"/> <addr> <country>Polska</country> <postalCode>31-867</postalCode> <city>Kraków</city> <streetName>Mikołaja Kopernika</streetName> <houseNumber>36</houseNumber> </addr> </representedOrganization> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.3.4424" assigningAuthorityName="CSIOZ" displayable="false"/> </representedCustodianOrganization> </assignedCustodian> </custodian> <legalAuthenticator> <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/> <time value="20150301122300"/> <signatureCode code="S"/> <assignedEntity> <id extension="712178" root="2.16.840.1.113883.3.4424.1.6.1" displayable="false"/> </assignedEntity> </legalAuthenticator> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.80"/> <structuredBody> <component> <section> <templateId root="1.3.6.1.4.1.19376.1.9.1.2.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.3.70"/> <id extension="543212345" root="2.16.840.1.113883.3.4424.2.7.99999.5.3"/> <code code="60590-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Dispensation"/> <title>Taksacja</title> <text> <paragraph ID="SPLY_1"> <caption>Wydano lek gotowy</caption> Nazwa: Morphini Sulfas WZF 0,1% Spinal <br/> Postać: roztwór do wstrzykiwań <br/> Moc: 0,1% <br/> Opakowanie: 10 amp. po 2 ml <br/> Ilość: 1 <br/> Nr serii: 123/456 <br/> Data ważności: 1 stycznia 2018 r. <br/> Identyfikator produktu: 5909990014958 (GS1/EAN) </paragraph> <paragraph ID="ACT_1"> Wartość wydanego leku: 50,00 <br/> Poziom odpłatności leku refundowanego: 100% <br/> Kwota refundacji: 0,00 <br/> Zapłacono: 50,60 </paragraph> </text> <entry> <supply classCode="SPLY" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.4"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.3"/> <templateId root="2.16.840.1.113883.10.20.1.34"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.62"/> <id extension="543223454" root="2.16.840.1.113883.3.4424.2.7.99999.5.1"/> <text> <reference value="#SPLY_1"/> </text> <quantity value="1"/> <product> <manufacturedProduct> <manufacturedMaterial> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.54"/> <code code="232121" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Morphini Sulfas WZF 0,1% Spinal roztwór do wstrzykiwań"/> <name>Morphini Sulfas WZF 0,1% Spinal</name> <pharm:formCode code="11201000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Solution for injection"/> <lotNumberText>123/456</lotNumberText> <pharm:expirationTime value="20180101"/> <pharm:asContent classCode="CONT"> <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE"> <pharm:code code="5909991040123" codeSystem="1.3.160" codeSystemName="GS1"/> <pharm:name>Morphini Sulfas WZF 0,1% Spinal (10 amp. 2ml)</pharm:name> <pharm:formCode code="30001000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Ampoule"/> <pharm:capacityQuantity value="2" unit="ml"/> <pharm:asSuperContent classCode="CONT"> <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE"> <pharm:capacityQuantity value="10"/> </pharm:containerPackagedMedicine> </pharm:asSuperContent> </pharm:containerPackagedMedicine> </pharm:asContent> </manufacturedMaterial> </manufacturedProduct> </product> <entryRelationship typeCode="REFR"> <substanceAdministration classCode="SBADM" moodCode="INT"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.11"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.63"/> <id extension="0700000000123456754321-1" root="2.16.840.1.113883.3.4424.8.10.1"/> <code code="PREItem" codeSystem="1.3.6.1.4.1.19376.1.9.2.2"/> <consumable> <manufacturedProduct> <manufacturedMaterial nullFlavor="NA"/> </manufacturedProduct> </consumable> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.77"/> <id extension="0700000000123456754321" root="2.16.840.1.113883.3.4424.8.10.2"/> <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document"/> </externalDocument> </reference> </substanceAdministration> </entryRelationship> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.67"/> <code code="TAKSL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Taksacja leku"/> <text> <reference value="#ACT_1"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="WWL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Wartość wydanego leku"/> <statusCode code="completed"/> <value xsi:type="REAL" value="50.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="RLPO" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Poziomy odpłatności leków refundowanych"/> <statusCode code="completed"/> <value xsi:type="CV" code="100%" codeSystem="2.16.840.1.113883.3.4424.11.1.1"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="INT"> <code code="KREF" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Kwota refundacji"/> <statusCode code="completed"/> <value xsi:type="REAL" value="0.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <code code="ZAPL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Zapłacono"/> <statusCode code="completed"/> <value xsi:type="REAL" value="50.00"/> </observation> </entryRelationship> </act> </entryRelationship> <reference typeCode="REFR"> <externalDocument> <templateId root="2.16.840.1.113883.3.4424.13.10.4.72"/> <id extension="12342/2017" root="2.16.840.1.113883.3.4424.8.11"/> </externalDocument> </reference> </supply> </entry> </section> </component> <component> <section> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1"/> <title>Dane o ubezpieczeniu i uprawnieniach</title> <text> <paragraph ID="ACT_2"> Oddział NFZ: 07 <br/> Uprawnienia dodatkowe: ZK (Nr leg.: 238/2015) </paragraph> </text> <entry> <act classCode="ACT" moodCode="DEF"> <templateId root="2.16.840.1.113883.10.20.1.20"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.51"/> <id nullFlavor="NA"/> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment source"/> <text> <reference value="#ACT_2"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.1.26"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.61"/> <id nullFlavor="NA"/> <code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4"> <qualifier> <name code="RLUD" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Refundacja leków wynikająca z uprawnień dodatkowych"/> <value code="ZK" displayName="ZK" codeSystem="2.16.840.1.113883.3.4424.11.3.1"/> </qualifier> </code> <statusCode code="completed"/> <performer typeCode="PRF">  <assignedEntity> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </assignedEntity> </performer> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.1.19"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.53"/> <id nullFlavor="NA"/> <code nullFlavor="NA"/> <entryRelationship typeCode="SUBJ"> <supply classCode="SPLY" moodCode="PRMS"> <id extension="543223454" root="2.16.840.1.113883.3.4424.2.7.99999.5.1"/> </supply> </entryRelationship> </act> </entryRelationship> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN">  <templateId root="2.16.840.1.113883.3.4424.13.10.4.59"/> <text>Nr leg.: 238/2015</text> </externalDocument> </reference> </act> </entryRelationship> </act> </entry> </section> </component> </structuredBody> </component></ClinicalDocument>

Przykład

<ClinicalDocument xsi:type="extPL:ClinicalDocument">  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.9.1.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.27" extension="1.3.1"/> <id extension="5432345" root="2.16.840.1.113883.3.4424.2.7.99999.5.1" displayable="true"/> <code code="60593-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication dispensed extended"> <translation code="04.12" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Realizacja recepty elektronicznej"> <qualifier> <name code="KDLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Kategoria dostępności leku"/> <value code="Rp" codeSystem="2.16.840.1.113883.3.4424.11.1.25"/> </qualifier> <qualifier> <name code="RLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj leku"/> <value code="R" displayName="Lek recepturowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wystawienia recepty"/> <value code="Z" displayName="Zwykła" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb realizacji recepty"/> <value code="Z" displayName="Zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="RRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj realizacji recepty"/> <value code="Z" displayName="zamykająca" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="PREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Postać recepty"/> <value code="E" displayName="elektroniczna" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wydania leku"/> <value code="Z" displayName="zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> </translation> </code> <title>Realizacja recepty elektronicznej</title> <effectiveTime value="20150301122300"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="8765456765" root="2.16.840.1.113883.3.4424.2.7.99999.5.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.88"/> <patientRole> <id extension="1234567" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/> <id extension="96013002256" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <addr> <country>Polska</country> <postalCode>58-200</postalCode> <city>Dzierżoniów</city> <streetName>Szpitalna</streetName> <houseNumber>3a</houseNumber> <unitID>10</unitID> </addr> <patient> <name> <given>Anna</given> <given>Maria</given> <family>Nowak</family> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/> <birthTime value="19960130"/> </patient> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.84"/> <functionCode code="FARM" codeSystem="2.16.840.1.113883.3.4424.11.3.18" codeSystemName="ZAWODY_MED" displayName="Farmaceuta"/> <time value="20150301122300"/> <assignedAuthor> <id extension="712178" root="2.16.840.1.13883.3.4424.1.6.1" displayable="true"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>mgr</prefix> <given>Miłosz</given> <family>Najman</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.31"/> <id extension="12003" root="2.16.840.1.113883.3.4424.2.6"/> <name>Apteka porcelanowa</name> <telecom use="PUB" value="tel:32123456"/> <addr> <country>Polska</country> <postalCode>31-867</postalCode> <city>Kraków</city> <streetName>Mikołaja Kopernika</streetName> <houseNumber>36</houseNumber> </addr> </representedOrganization> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.3.4424" assigningAuthorityName="CSIOZ" displayable="false"/> </representedCustodianOrganization> </assignedCustodian> </custodian> <legalAuthenticator> <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/> <time value="20150301122300"/> <signatureCode code="S"/> <assignedEntity> <id extension="712178" root="2.16.840.1.113883.3.4424.1.6.1" displayable="false"/> </assignedEntity> </legalAuthenticator> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.80"/> <structuredBody> <component> <section> <templateId root="1.3.6.1.4.1.19376.1.9.1.2.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.3.70"/> <id extension="234565432345" root="2.16.840.1.113883.3.4424.2.7.99999.5.3"/> <code code="60590-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Dispensation"/> <title>Wydanie leku</title> <text> <paragraph ID="SPLY_1"> <caption>Wydanie leku recepturowego</caption> Receptura: <br/> Lanolini 25,0 <br/> Vaselini albi 25,0 <br/> Paraffini liq. 10,0 <br/> Aquae aa ad 100,0 <br/> Postać: maść <br/> Ilość: 100 g <br/> </paragraph> <paragraph ID="ACT_1"> <caption>Taksacja:</caption> Wartość wydanego leku: 30,00 <br/> Poziom odpłatności leku refundowanego: 30% <br/> Kwota refundacji: 21,00 <br/> Zapłacono: 9,00 <br/> Taksa laborum: 12,33 </paragraph> </text> <entry> <supply classCode="SPLY" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.4"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.3"/> <templateId root="2.16.840.1.113883.10.20.1.34"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.62"/> <id extension="3243432" root="2.16.840.1.113883.3.4424.2.7.99999.5.1"/> <text> <reference value="#SPLY_1"/> </text> <quantity value="100" unit="g"/> <product> <manufacturedProduct> <manufacturedMaterial> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.70"/> <code nullFlavor="NA"/> <name>Maść pośladkowa</name> <pharm:formCode code="10504000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Ointment"/> <pharm:ingredient classCode="ACTI"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.71"/> <pharm:quantity> <numerator xsi:type="PQ" value="25" unit="g"/> <denominator xsi:type="PQ" value="1"/> </pharm:quantity> <pharm:ingredient classCode="MMAT" determinerCode="KIND"> <pharm:code code="23432" codeSystem="2.16.840.1.113883.3.4424.6.3" displayName="Wazelina biała"/> <pharm:name>Vaselinum album</pharm:name> </pharm:ingredient> </pharm:ingredient> <pharm:ingredient classCode="ACTI"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.71"/> <pharm:quantity> <numerator xsi:type="PQ" value="25" unit="g"/> <denominator xsi:type="PQ" value="1"/> </pharm:quantity> <pharm:ingredient classCode="MMAT" determinerCode="KIND"> <pharm:code code="34543" codeSystem="2.16.840.1.113883.3.4424.6.3" displayName="Lanolina"/> <pharm:name>Lanolinum</pharm:name> </pharm:ingredient> </pharm:ingredient> <pharm:ingredient classCode="ACTI"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.71"/> <pharm:quantity> <numerator xsi:type="PQ" value="10" unit="g"/> <denominator xsi:type="PQ" value="1"/> </pharm:quantity> <pharm:ingredient classCode="MMAT" determinerCode="KIND"> <pharm:code code="45654" codeSystem="2.16.840.1.113883.3.4424.6.3" displayName="Parafina ciekła"/> <pharm:name>Paraffinum liquidum</pharm:name> </pharm:ingredient> </pharm:ingredient> <pharm:ingredient classCode="ACTI"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.71"/> <pharm:ingredient classCode="MMAT" determinerCode="KIND"> <pharm:code code="56765" codeSystem="2.16.840.1.113883.3.4424.6.3" displayName="Woda do receptury aptecznej FP"/> <pharm:name>Aqua</pharm:name> </pharm:ingredient> </pharm:ingredient> </manufacturedMaterial> </manufacturedProduct> </product> <entryRelationship typeCode="REFR"> <substanceAdministration classCode="SBADM" moodCode="INT"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.11"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.63"/> <id extension="656789-1" root="2.16.840.1.113883.3.4424.2.7.99999.2.3"/> <code code="PREItem" codeSystem="1.3.6.1.4.1.19376.1.9.2.2"/> <consumable> <manufacturedProduct> <manufacturedMaterial nullFlavor="NA"/> </manufacturedProduct> </consumable> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.77"/> <id extension="0700000000123456712345" root="2.16.840.1.113883.3.4424.8.10.1"/> <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document"/> </externalDocument> </reference> </substanceAdministration> </entryRelationship> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.67"/> <code code="TAKSL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Taksacja leku"/> <text> <reference value="#ACT_1"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="WWL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Wartość wydanego leku"/> <statusCode code="completed"/> <value xsi:type="REAL" value="30.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="RLPO" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Poziomy odpłatności leków refundowanych"/> <statusCode code="completed"/> <value xsi:type="CV" code="30%" codeSystem="2.16.840.1.113883.3.4424.11.1.1"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="INT"> <code code="KREF" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Kwota refundacji"/> <statusCode code="completed"/> <value xsi:type="REAL" value="21.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <code code="ZAPL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Zapłacono"/> <statusCode code="completed"/> <value xsi:type="REAL" value="9.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <code code="TAKL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Taksa laborum"/> <statusCode code="completed"/> <value xsi:type="REAL" value="12.33"/> </observation> </entryRelationship> </act> </entryRelationship> </supply> </entry> </section> </component> <component> <section> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1"/> <title>Dane o ubezpieczeniu i uprawnieniach</title> <text> <paragraph ID="ACT_2"> Oddział NFZ: 07 <br/> Uprawnienia dodatkowe: ZK (Nr leg.: 238/2015) </paragraph> </text> <entry> <act classCode="ACT" moodCode="DEF"> <templateId root="2.16.840.1.113883.10.20.1.20"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.51"/> <id nullFlavor="NA"/> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment source"/> <text> <reference value="#ACT_2"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.1.26"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.61"/> <id nullFlavor="NA"/> <code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4"> <qualifier> <name code="RLUD" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Refundacja leków wynikająca z uprawnień dodatkowych"/> <value code="ZK" displayName="ZK" codeSystem="2.16.840.1.113883.3.4424.11.3.1"/> </qualifier> </code> <statusCode code="completed"/> <performer typeCode="PRF">  <assignedEntity> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </assignedEntity> </performer> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.1.19"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.53"/> <id nullFlavor="NA"/> <code nullFlavor="NA"/> <entryRelationship typeCode="SUBJ"> <supply classCode="SPLY" moodCode="PRMS"> <id extension="3243432" root="2.16.840.1.113883.3.4424.2.7.99999.5.1"/> </supply> </entryRelationship> </act> </entryRelationship>  <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.59"/> <text>Nr leg.: 238/2015</text> </externalDocument> </reference> </act> </entryRelationship> </act> </entry> </section> </component> </structuredBody> </component></ClinicalDocument>

Przykład

<ClinicalDocument xsi:type="extPL:ClinicalDocument">  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.9.1.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.27" extension="1.3.1"/> <id extension="543223454" root="2.16.840.1.113883.3.4424.2.7.99999.5.1" displayable="true"/> <code code="60593-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication dispensed extended"> <translation code="04.12" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Realizacja recepty elektronicznej"> <qualifier> <name code="KDLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Kategoria dostępności leku"/> <value code="Rp" codeSystem="2.16.840.1.113883.3.4424.11.1.25"/> </qualifier> <qualifier> <name code="RLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj leku"/> <value code="G" displayName="Lek gotowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wystawienia recepty"/> <value code="Z" displayName="Zwykła" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb realizacji recepty"/> <value code="Z" displayName="Zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="RRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj realizacji recepty"/> <value code="C" displayName="częściowa" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="PREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Postać recepty"/> <value code="E" displayName="elektroniczna" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wydania leku"/> <value code="Z" displayName="zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> </translation> </code> <title>Realizacja recepty elektronicznej</title> <effectiveTime value="20150301122300"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="24543234" root="2.16.840.1.113883.3.4424.2.7.99999.5.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.88"/> <patientRole> <id extension="1234567" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/> <id extension="96013002256" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <addr> <country>Polska</country> <postalCode>58-200</postalCode> <city>Dzierżoniów</city> <streetName>Szpitalna</streetName> <houseNumber>3a</houseNumber> <unitID>10</unitID> </addr> <patient> <name> <given>Anna</given> <given>Maria</given> <family>Nowak</family> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/> <birthTime value="19960130"/> </patient> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.84"/> <functionCode code="TFARM" codeSystem="2.16.840.1.113883.3.4424.11.3.18" codeSystemName="ZAWODY_MED" displayName="Technik farmaceutyczny"/> <time value="20150301122300"/> <assignedAuthor xsi:type="extPL:AssignedAuthor"> <id extension="83120199999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>tech. farm.</prefix> <given>Jerzy</given> <family>Miarka</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.31"/> <id extension="12003" root="2.16.840.1.113883.3.4424.2.6"/> <name>Apteka porcelanowa</name> <telecom use="PUB" value="tel:32123456"/> <addr> <country>Polska</country> <postalCode>31-867</postalCode> <city>Kraków</city> <streetName>Mikołaja Kopernika</streetName> <houseNumber>36</houseNumber> </addr> </representedOrganization> <extPL:boundedBy typeCode="PART"> <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/> <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT"> <extPL:id extension="123456" root="2.16.840.1.113883.3.4424.8.6.3.7"/> <extPL:bounding typeCode="PART"> <extPL:reimburser classCode="UNDWRT"> <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </extPL:reimburser> </extPL:bounding> </extPL:reimbursementRelatedContract> </extPL:boundedBy> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <representedCustodianOrganization> <id extension="83120199999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="false"/> </representedCustodianOrganization> </assignedCustodian> </custodian> <legalAuthenticator> <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/> <time value="20150301122300"/> <signatureCode code="S"/> <assignedEntity> <id extension="712178" root="2.16.840.1.113883.3.4424.1.6.1" displayable="false"/> </assignedEntity> </legalAuthenticator> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.80"/> <structuredBody> <component> <section> <templateId root="1.3.6.1.4.1.19376.1.9.1.2.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.3.70"/> <id extension="543212345" root="2.16.840.1.113883.3.4424.2.7.99999.5.3"/> <code code="60590-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Dispensation"/> <title>Wydanie leku</title> <text> <paragraph ID="SPLY_1"> <caption>Wydano lek gotowy</caption> Nazwa: Enarenal <br/> Postać: tabletki <br/> Dawka: 5mg <br/> Opakowanie: 60 tabl. <br/> Ilość: 1 <br/> Nr serii: 123/890 <br/> Data ważności: 1 stycznia 2018 r. <br/> Identyfikator produktu: 5909990014958 (GS1/EAN) </paragraph> <paragraph ID="ACT_1"> <caption>Taksacja</caption> Wartość wydanego leku: 12,00 <br/> Limit urzędowy: 8,40 <br/> Poziom odpłatności leku refundowanego: 30% <br/> Kwota refundacji: 8,40 <br/> Zapłacono: 3,60 </paragraph> </text> <entry> <supply classCode="SPLY" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.4"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.3"/> <templateId root="2.16.840.1.113883.10.20.1.34"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.62"/> <id extension="543223454" root="2.16.840.1.113883.3.4424.2.7.99999.5.1"/> <text> <reference value="#SPLY_1"/> </text> <quantity value="1"/> <product> <manufacturedProduct> <manufacturedMaterial> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.54"/> <code code="4321" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Enarenal 5mg tabl."/> <name>Enarenal 5mg tabletki</name> <lotNumberText>123/890</lotNumberText> <pharm:expirationTime value="20180101"/> <pharm:asContent classCode="CONT"> <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE"> <pharm:code code="5909990014958" codeSystem="1.3.160" codeSystemName="GS1"/> <pharm:name>Enarenal 5mg (60 tabl.)</pharm:name> <pharm:formCode code="30066000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Tablet container"/> <pharm:capacityQuantity value="60"/> </pharm:containerPackagedMedicine> </pharm:asContent> </manufacturedMaterial> </manufacturedProduct> </product> <entryRelationship typeCode="REFR"> <substanceAdministration classCode="SBADM" moodCode="INT"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.11"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.63"/> <id extension="2343aab-1" root="2.16.840.1.113883.3.4424.2.7.99999.2.3"/> <code code="PREItem" codeSystem="1.3.6.1.4.1.19376.1.9.2.2"/> <consumable> <manufacturedProduct> <manufacturedMaterial nullFlavor="NA"/> </manufacturedProduct> </consumable> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.77"/> <id extension="0700000000123456789213" root="2.16.840.1.113883.3.4424.8.10.1"/> <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document"/> </externalDocument> </reference> </substanceAdministration> </entryRelationship> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.67"/> <code code="TAKSL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Taksacja leku"/> <text> <reference value="#ACT_1"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="WWL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Wartość wydanego leku"/> <statusCode code="completed"/> <value xsi:type="REAL" value="12.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="LIMU" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Limit urzędowy"/> <statusCode code="completed"/> <value xsi:type="REAL" value="8.40"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="RLPO" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Poziomy odpłatności leków refundowanych"/> <statusCode code="completed"/> <value xsi:type="CV" code="30%" codeSystem="2.16.840.1.113883.3.4424.11.1.1"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="INT"> <code code="KREF" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Kwota refundacji"/> <statusCode code="completed"/> <value xsi:type="REAL" value="8.40"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <code code="ZAPL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Zapłacono"/> <statusCode code="completed"/> <value xsi:type="REAL" value="3.60"/> </observation> </entryRelationship> </act> </entryRelationship> </supply> </entry> </section> </component> <component> <section> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1"/> <title>Dane o ubezpieczeniu i uprawnieniach</title> <text> <paragraph ID="ACT_2"> Oddział NFZ: 07 <br/> Uprawnienia dodatkowe: ZK (Nr leg.: 238/2015) </paragraph> </text> <entry> <act classCode="ACT" moodCode="DEF"> <templateId root="2.16.840.1.113883.10.20.1.20"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.51"/> <id nullFlavor="NA"/> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment source"/> <text> <reference value="#ACT_2"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.1.26"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.61"/> <id nullFlavor="NA"/> <id nullFlavor="NA"/> <code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4"> <qualifier> <name code="RLUD" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Refundacja leków wynikająca z uprawnień dodatkowych"/> <value code="ZK" displayName="ZK" codeSystem="2.16.840.1.113883.3.4424.11.3.1"/> </qualifier> </code> <statusCode code="completed"/> <performer typeCode="PRF">  <assignedEntity> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </assignedEntity> </performer> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.1.19"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.53"/> <id nullFlavor="NA"/> <code nullFlavor="NA"/> <entryRelationship typeCode="SUBJ"> <supply classCode="SPLY" moodCode="PRMS"> <id extension="543212345" root="2.16.840.1.113883.3.4424.2.7.99999.5.3"/> </supply> </entryRelationship> </act> </entryRelationship> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN">  <templateId root="2.16.840.1.113883.3.4424.13.10.4.59"/> <text>Nr leg.: 238/2015</text> </externalDocument> </reference> </act> </entryRelationship> </act> </entry> </section> </component> <component> <section> <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/> <text> <paragraph> <caption>Adnotacja farmaceuty</caption> Wydano zamiennik </paragraph> </text> </section> </component> </structuredBody> </component></ClinicalDocument>

Przykład

<ClinicalDocument xsi:type="extPL:ClinicalDocument">  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.9.1.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.27" extension="1.3.1"/> <id extension="bc34221ax" root="2.16.840.1.113883.3.4424.2.7.99999.5.1" displayable="true"/> <code code="60593-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication dispensed extended"> <translation code="04.12" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Realizacja recepty elektronicznej"> <qualifier> <name code="KDLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Kategoria dostępności leku"/> <value code="Rpw" codeSystem="2.16.840.1.113883.3.4424.11.1.25"/> </qualifier> <qualifier> <name code="RLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj leku"/> <value code="G" displayName="Lek gotowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wystawienia recepty"/> <value code="Z" displayName="Zwykła" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb realizacji recepty"/> <value code="Z" displayName="Zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="RRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj realizacji recepty"/> <value code="W" displayName="wycofująca" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="PREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Postać recepty"/> <value code="E" displayName="elektroniczna" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wydania leku"/> <value code="Z" displayName="zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> </translation> </code> <title>Realizacja recepty elektronicznej</title> <effectiveTime value="20150301122300"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="432321" root="2.16.840.1.113883.3.4424.2.7.99999.5.2"/> <versionNumber value="2"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.88"/> <patientRole> <id extension="1234567" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/> <id extension="96013002256" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <addr> <country>Polska</country> <postalCode>58-200</postalCode> <city>Dzierżoniów</city> <streetName>Szpitalna</streetName> <houseNumber>3a</houseNumber> <unitID>10</unitID> </addr> <patient> <name> <given>Anna</given> <given>Maria</given> <family>Nowak</family> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/> <birthTime value="19960130"/> </patient> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.84"/> <functionCode code="FARM" codeSystem="2.16.840.1.113883.3.4424.11.3.18" codeSystemName="ZAWODY_MED" displayName="Farmaceuta"/> <time value="20150301122300"/> <assignedAuthor> <id extension="712178" root="2.16.840.1.113883.3.4424.1.6.1" displayable="true"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>mgr</prefix> <given>Miłosz</given> <family>Najman</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.31"/> <id extension="12003" root="2.16.840.1.113883.3.4424.2.6"/> <name>Apteka porcelanowa</name> <telecom use="PUB" value="tel:32123456"/> <addr> <country>Polska</country> <postalCode>31-867</postalCode> <city>Kraków</city> <streetName>Mikołaja Kopernika</streetName> <houseNumber>36</houseNumber> </addr> </representedOrganization> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.3.4424" assigningAuthorityName="CSIOZ" displayable="false"/> </representedCustodianOrganization> </assignedCustodian> </custodian> <legalAuthenticator> <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/> <time value="20150301122300"/> <signatureCode code="S"/> <assignedEntity> <id extension="712178" root="2.16.840.1.113883.3.4424.1.6.1" displayable="false"/> </assignedEntity> </legalAuthenticator> <relatedDocument typeCode="RPLC"> <templateId root="2.16.840.1.113883.3.4424.13.10.2.83"/> <parentDocument classCode="DOCCLIN" moodCode="EVN"> <id extension="232123" root="2.16.840.1.113883.3.4424.2.7.99999.5.1" displayable="true"/> <code code="60593-1" codeSystem="2.16.840.1.113883.6.1"/> <setId extension="432321" root="2.16.840.1.113883.3.4424.2.7.99999.5.2"/> <versionNumber value="1"/> </parentDocument> </relatedDocument> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.80"/> <structuredBody> <component> <section> <templateId root="1.3.6.1.4.1.19376.1.9.1.2.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.3.70"/> <id extension="12345" root="2.16.840.1.113883.3.4424.2.7.99999.5.3"/> <code code="60590-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Dispensation"/> <title>Wydanie leku</title> <text> <paragraph ID="SPLY_1"> <caption>Wydano lek gotowy</caption> Nazwa: MST Continus <br/> Postać: tabletki <br/> Dawka: 100mg <br/> Opakowanie: 30 tabl. <br/> Ilość: 1 <br/> Identyfikator produktu: 5909990476527 (GS1/EAN) </paragraph> <paragraph ID="ACT_1"> <caption>Taksacja:</caption> s Wartość wydanego leku: 0,00 <br/> Limit urzędowy: 7,01 <br/> Poziom odpłatności leku refundowanego: R <br/> Kwota refundacji: 7,01 <br/> Zapłacono: 0,00 </paragraph> </text> <entry> <supply classCode="SPLY" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.4"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.3"/> <templateId root="2.16.840.1.113883.10.20.1.34"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.62"/> <id extension="bc34221ax" root="2.16.840.1.113883.3.4424.2.7.99999.5.1"/> <text> <reference value="#SPLY_1"/> </text> <effectiveTime value="20150212"/> <quantity value="0"/> <product> <manufacturedProduct> <manufacturedMaterial> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.54"/> <code code="4321" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="MST Continus 100mg tabl. powl. o zmod. uwalnianiu"/> <name>MST Continus 100mg tabletki</name> <pharm:asContent classCode="CONT"> <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE"> <pharm:code code="5909990476527" codeSystem="1.3.160" codeSystemName="GS1"/> <pharm:name>MST Continus 100mg tabl. powl. o zmod. uwalnianiu (30 tabl.)</pharm:name> <pharm:formCode code="30066000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Tablet container"/> <pharm:capacityQuantity value="30"/> </pharm:containerPackagedMedicine> </pharm:asContent> </manufacturedMaterial> </manufacturedProduct> </product> <entryRelationship typeCode="REFR"> <substanceAdministration classCode="SBADM" moodCode="INT"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.11"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.63"/> <id extension="ff3432b-1" root="2.16.840.1.113883.3.4424.2.7.99999.2.3"/> <code code="PREItem" codeSystem="1.3.6.1.4.1.19376.1.9.2.2"/> <consumable> <manufacturedProduct> <manufacturedMaterial nullFlavor="NA"/> </manufacturedProduct> </consumable> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.77"/> <id extension="0700000000123456789009" root="2.16.840.1.113883.3.4424.8.10.1"/> <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document"/> </externalDocument> </reference> </substanceAdministration> </entryRelationship> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.67"/> <code code="TAKSL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Taksacja leku"/> <text> <reference value="#ACT_1"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="WWL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Wartość wydanego leku"/> <statusCode code="completed"/> <value xsi:type="REAL" value="0.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="LIMU" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Limit urzędowy"/> <statusCode code="completed"/> <value xsi:type="REAL" value="7.01"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="RLPO" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Poziomy odpłatności leków refundowanych"/> <statusCode code="completed"/> <value xsi:type="CV" code="R" codeSystem="2.16.840.1.113883.3.4424.11.1.1"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="INT"> <code code="KREF" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Kwota refundacji"/> <statusCode code="completed"/> <value xsi:type="REAL" value="7.01"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <code code="ZAPL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Zapłacono"/> <statusCode code="completed"/> <value xsi:type="REAL" value="0.00"/> </observation> </entryRelationship> </act> </entryRelationship> </supply> </entry> </section> </component> <component> <section> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1"/> <title>Dane o ubezpieczeniu i uprawnieniach</title> <text> <paragraph ID="ACT_2"> Oddział NFZ: 07 <br/> Uprawnienia dodatkowe: ZK (Nr leg.: 238/2015) </paragraph> </text> <entry> <act classCode="ACT" moodCode="DEF"> <templateId root="2.16.840.1.113883.10.20.1.20"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.51"/> <id nullFlavor="NA"/> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment source"/> <text> <reference value="#ACT_2"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.1.26"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.61"/> <id nullFlavor="NA"/> <id nullFlavor="NA"/> <code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4"> <qualifier> <name code="RLUD" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Refundacja leków wynikająca z uprawnień dodatkowych"/> <value code="ZK" displayName="ZK" codeSystem="2.16.840.1.113883.3.4424.11.3.1"/> </qualifier> </code> <statusCode code="completed"/> <performer typeCode="PRF">  <assignedEntity> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </assignedEntity> </performer> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.1.19"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.53"/> <id nullFlavor="NA"/> <code nullFlavor="NA"/> <entryRelationship typeCode="SUBJ"> <supply classCode="SPLY" moodCode="PRMS"> <id extension="bc34221ax" root="2.16.840.1.113883.3.4424.2.7.99999.5.1"/> </supply> </entryRelationship> </act> </entryRelationship> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN">  <templateId root="2.16.840.1.113883.3.4424.13.10.4.59"/> <text>Nr leg.: 238/2015</text> </externalDocument> </reference> </act> </entryRelationship> </act> </entry> </section> </component> </structuredBody> </component></ClinicalDocument>

Przykład

<ClinicalDocument xsi:type="extPL:ClinicalDocument">  <typeId extension="POCD_HD000040" root="2.16.840.1.113883.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.9.1.1.3"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.1.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.1.27" extension="1.3.1"/> <id extension="543223454" root="2.16.840.1.113883.3.4424.2.7.99999.5.1" displayable="true"/> <code code="60593-1" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Medication dispensed extended"> <translation code="04.13" codeSystem="2.16.840.1.113883.3.4424.11.1.32" codeSystemName="KLAS_DOK_P1" displayName="Realizacja recepty papierowej"> <qualifier> <name code="KDLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Kategoria dostępności leku"/> <value code="Rp" codeSystem="2.16.840.1.113883.3.4424.11.1.25"/> </qualifier> <qualifier> <name code="RLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj leku"/> <value code="G" displayName="Lek gotowy" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wystawienia recepty"/> <value code="Z" displayName="Zwykła" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb realizacji recepty"/> <value code="Z" displayName="Zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="RRREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj realizacji recepty"/> <value code="C" displayName="częściowa" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="PREC" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Postać recepty"/> <value code="P" displayName="papierowa" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="RRECP" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Rodzaj recepty papierowej"/> <value code="PF" displayName="pro familia" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> <qualifier> <name code="TWLEK" codeSystem="2.16.840.1.113883.3.4424.13.5.1" codeSystemName="PolskieKlasyfikatoryHL7v3" displayName="Tryb wydania leku"/> <value code="Z" displayName="zwykły" codeSystem="2.16.840.1.113883.3.4424.13.5.1"/> </qualifier> </translation> </code> <title>Realizacja recepty papierowej</title> <effectiveTime value="20150301122300"/> <confidentialityCode code="N" codeSystem="2.16.840.1.113883.5.25"/> <languageCode code="pl-PL"/> <setId extension="24543234" root="2.16.840.1.113883.3.4424.2.7.99999.5.2"/> <versionNumber value="1"/> <recordTarget> <templateId root="2.16.840.1.113883.3.4424.13.10.2.88"/> <patientRole> <id extension="1234567" root="2.16.840.1.113883.3.4424.2.7.0.17.1" displayable="false"/> <id extension="96013002256" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <addr> <country>Polska</country> <postalCode>58-200</postalCode> <city>Dzierżoniów</city> <streetName>Szpitalna</streetName> <houseNumber>3a</houseNumber> <unitID>10</unitID> </addr> <patient> <name> <given>Anna</given> <given>Maria</given> <family>Nowak</family> </name> <administrativeGenderCode code="F" codeSystem="2.16.840.1.113883.5.1"/> <birthTime value="19960130"/> </patient> </patientRole> </recordTarget> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.2.84"/> <functionCode code="TFARM" codeSystem="2.16.840.1.113883.3.4424.11.3.18" codeSystemName="ZAWODY_MED" displayName="Technik farmaceutyczny"/> <time value="20150301122300"/> <assignedAuthor xsi:type="extPL:AssignedAuthor"> <id extension="83120199999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="true"/> <assignedPerson> <templateId root="2.16.840.1.113883.3.4424.13.10.2.1"/> <name> <prefix>tech. farm.</prefix> <given>Jerzy</given> <family>Miarka</family> </name> </assignedPerson> <representedOrganization> <templateId root="2.16.840.1.113883.3.4424.13.10.2.31"/> <id extension="12003" root="2.16.840.1.113883.3.4424.2.6"/> <name>Apteka porcelanowa</name> <telecom use="PUB" value="tel:32123456"/> <addr> <country>Polska</country> <postalCode>31-867</postalCode> <city>Kraków</city> <streetName>Mikołaja Kopernika</streetName> <houseNumber>36</houseNumber> </addr> </representedOrganization> <extPL:boundedBy typeCode="PART"> <extPL:templateId root="2.16.840.1.113883.3.4424.13.10.2.44"/> <extPL:reimbursementRelatedContract moodCode="EVN" classCode="CNTRCT"> <extPL:id extension="123456" root="2.16.840.1.113883.3.4424.8.6.3.7"/> <extPL:bounding typeCode="PART"> <extPL:reimburser classCode="UNDWRT"> <extPL:id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </extPL:reimburser> </extPL:bounding> </extPL:reimbursementRelatedContract> </extPL:boundedBy> </assignedAuthor> </author> <custodian> <templateId root="2.16.840.1.113883.3.4424.13.10.2.20"/> <assignedCustodian> <representedCustodianOrganization> <id root="2.16.840.1.113883.3.4424" assigningAuthorityName="CSIOZ" displayable="false"/> </representedCustodianOrganization> </assignedCustodian> </custodian> <legalAuthenticator> <templateId root="2.16.840.1.113883.3.4424.13.10.2.6"/> <time value="20150301122300"/> <signatureCode code="S"/> <assignedEntity> <id extension="83120199999" root="2.16.840.1.113883.3.4424.1.1.616" displayable="false"/> </assignedEntity> </legalAuthenticator> <component> <templateId root="2.16.840.1.113883.3.4424.13.10.2.80"/> <structuredBody> <component> <section> <templateId root="1.3.6.1.4.1.19376.1.9.1.2.3"/> <templateId root="2.16.840.1.113883.3.4424.13.10.3.70"/> <id extension="543212345" root="2.16.840.1.113883.3.4424.2.7.99999.5.3"/> <code code="60590-7" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Dispensation"/> <title>Wydanie leku</title> <text> <paragraph ID="SPLY_1"> <caption>Wydano lek gotowy</caption> Nazwa: Polpril <br/> Postać: tabletki <br/> Dawka: 5mg <br/> Opakowanie: 28 tabl. <br/> Ilość: 1 <br/> Identyfikator produktu: 5909990924646 (GS1/EAN) <br/> <content ID="ACT_1">Wydano zamiennik</content> </paragraph> <paragraph ID="ACT_2"> <caption>Taksacja</caption> Wartość wydanego leku: 12,00 <br/> Limit urzędowy: 8,40 <br/> Poziom odpłatności leku refundowanego: 30% <br/> Kwota refundacji: 8,40 <br/> Zapłacono: 3,60 </paragraph> </text> <entry> <supply classCode="SPLY" moodCode="EVN"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.4"/> <templateId root="1.3.6.1.4.1.19376.1.5.3.1.4.7.3"/> <templateId root="2.16.840.1.113883.10.20.1.34"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.62"/> <id extension="543223454" root="2.16.840.1.113883.3.4424.2.7.99999.5.1"/> <text> <reference value="#SPLY_1"/> </text> <quantity value="1"/> <product> <manufacturedProduct> <manufacturedMaterial> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.1"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.54"/> <code code="4321" codeSystem="2.16.840.1.113883.3.4424.6.1" displayName="Enarenal 5mg tabl."/> <name>Polpril 5mg tabletki</name> <pharm:asContent classCode="CONT"> <pharm:containerPackagedMedicine classCode="CONT" determinerCode="INSTANCE"> <pharm:code code="5909990924646" codeSystem="1.3.160" codeSystemName="GS1"/> <pharm:name>Polpril 5mg (28 tabl.)</pharm:name> <pharm:formCode code="30066000" codeSystem="0.4.0.127.0.16.1.1.2.1" codeSystemName="EDQM" displayName="Tablet container"/> <pharm:capacityQuantity value="28"/> </pharm:containerPackagedMedicine> </pharm:asContent> </manufacturedMaterial> </manufacturedProduct> </product> <entryRelationship typeCode="REFR"> <substanceAdministration classCode="SBADM" moodCode="INT"> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.11"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.63"/> <id extension="0700000000123456789012-1" root="2.16.840.1.113883.3.4424.8.10.1"/> <code code="PREItem" codeSystem="1.3.6.1.4.1.19376.1.9.2.2"/> <consumable> <manufacturedProduct> <manufacturedMaterial nullFlavor="NA"/> </manufacturedProduct> </consumable> <author> <templateId root="2.16.840.1.113883.3.4424.13.10.4.78"/> <time value="20150227"/> <assignedAuthor> <id extension="7724513" root="2.16.840.1.113883.3.4424.1.6.2" displayable="true"/> <representedOrganization> <id extension="123456789" root="2.16.840.1.113883.3.4424.2.2.1" displayable="true"/> </representedOrganization> </assignedAuthor> </author> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.77"/> <id extension="0700000000123456789012" root="2.16.840.1.113883.3.4424.8.10.2"/> <code code="57833-6" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Prescription for medication Document"/> </externalDocument> </reference> </substanceAdministration> </entryRelationship> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.79"/> <templateId root="1.3.6.1.4.1.19376.1.9.1.3.9.2"/> <code code="E" codeSystem="2.16.840.1.113883.5.1070" codeSystemName="HL7 Substance Admin Substitution" displayName="equivalent"/> <text> <reference value="#ACT_1"/> </text> <statusCode code="completed"/> </act> </entryRelationship> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.3.4424.13.10.4.67"/> <code code="TAKSL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Taksacja leku"/> <text> <reference value="#ACT_2"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="WWL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Wartość wydanego leku"/> <statusCode code="completed"/> <value xsi:type="REAL" value="12.00"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="LIMU" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Limit urzędowy"/> <statusCode code="completed"/> <value xsi:type="REAL" value="8.40"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="DEF"> <code code="RLPO" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Poziomy odpłatności leków refundowanych"/> <statusCode code="completed"/> <value xsi:type="CV" code="30%" codeSystem="2.16.840.1.113883.3.4424.11.1.1"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="INT"> <code code="KREF" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Kwota refundacji"/> <statusCode code="completed"/> <value xsi:type="REAL" value="8.40"/> </observation> </entryRelationship> <entryRelationship typeCode="COMP"> <observation classCode="OBS" moodCode="EVN"> <code code="ZAPL" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Zapłacono"/> <statusCode code="completed"/> <value xsi:type="REAL" value="3.60"/> </observation> </entryRelationship> </act> </entryRelationship> </supply> </entry> </section> </component> <component> <section> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1"/> <title>Dane o ubezpieczeniu i uprawnieniach</title> <text> <paragraph ID="ACT_3"> Oddział NFZ: 07 <br/> Uprawnienia dodatkowe: ZK (Nr leg.: 238/2015) </paragraph> </text> <entry> <act classCode="ACT" moodCode="DEF"> <templateId root="2.16.840.1.113883.10.20.1.20"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.51"/> <id nullFlavor="NA"/> <code code="48768-6" codeSystem="2.16.840.1.113883.6.1" displayName="Payment source"/> <text> <reference value="#ACT_3"/> </text> <statusCode code="completed"/> <entryRelationship typeCode="COMP"> <act classCode="ACT" moodCode="EVN">  <templateId root="2.16.840.1.113883.10.20.1.26"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.61"/> <id nullFlavor="NA"/> <id nullFlavor="NA"/> <code code="PUBLICPOL" codeSystem="2.16.840.1.113883.5.4"> <qualifier> <name code="RLUD" codeSystem="2.16.840.1.113883.3.4424.13.5.1" displayName="Refundacja leków wynikająca z uprawnień dodatkowych"/> <value code="ZK" displayName="ZK" codeSystem="2.16.840.1.113883.3.4424.11.3.1"/> </qualifier> </code> <statusCode code="completed"/> <performer typeCode="PRF">  <assignedEntity> <id extension="07" root="2.16.840.1.113883.3.4424.3.1" displayable="true"/> </assignedEntity> </performer> <entryRelationship typeCode="REFR"> <act classCode="ACT" moodCode="EVN"> <templateId root="2.16.840.1.113883.10.20.1.19"/> <templateId root="2.16.840.1.113883.3.4424.13.10.4.53"/> <id nullFlavor="NA"/> <code nullFlavor="NA"/> <entryRelationship typeCode="SUBJ"> <supply classCode="SPLY" moodCode="PRMS"> <id extension="543212345" root="2.16.840.1.113883.3.4424.2.7.99999.5.3"/> </supply> </entryRelationship> </act> </entryRelationship> <reference typeCode="REFR"> <externalDocument classCode="DOC" moodCode="EVN">  <templateId root="2.16.840.1.113883.3.4424.13.10.4.59"/> <text>Nr leg.: 238/2015</text> </externalDocument> </reference> </act> </entryRelationship> </act> </entry> </section> </component> <component> <section> <code code="48767-8" codeSystem="2.16.840.1.113883.6.1" codeSystemName="LOINC" displayName="Annotation comment"/> <text> <paragraph> <caption>Adnotacja farmaceuty</caption> Wydano zamiennik </paragraph> </text> </section> </component> </structuredBody> </component></ClinicalDocument>

Pozycja Typ danych Krotność Wymagalność Opis Etykieta

hl7:ClinicalDocument 1 … 1 M (plCnse)

@classCode 0 … 1 F DOCCLIN

@moodCode 0 … 1 F EVN

hl7:typeId II 1 … 1 M (plCnse)

@extension 1 … 1 F POCD_HD000040

@root 1 … 1 F 2.16.840.1.113883.1.3

hl7:templateId II 1 … 1 M (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.13.10.1.27']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.1.27

@extension st 0 … 1

hl7:templateId II 1 … 1 M (plCnse)

gdzie [@root='1.3.6.1.4.1.19376.1.9.1.1.3']

@root 1 … 1 F 1.3.6.1.4.1.19376.1.9.1.1.3

hl7:templateId II 1 … 1 R (plCnse)

gdzie [@root='1.3.6.1.4.1.19376.1.5.3.1.1.1']

@root 1 … 1 F 1.3.6.1.4.1.19376.1.5.3.1.1.1

hl7:id II 1 … 1 M (plCnse)

@root uid 1 … 1 R

@extension st 1 … 1 R

hl7:code CE 1 … 1 M (plCnse)

@code CONF 1 … 1 F 60593-1

@codeSystem 1 … 1 F 2.16.840.1.113883.6.1 (LOINC)

@codeSystemName 1 … 1 F LOINC

@displayName 1 … 1 F Medication dispensed extended

hl7:translation 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.84 Typ dokumentu realizacji recepty (DYNAMICZNE)

hl7:qualifier CR 1 … 1 M (plCnse)

gdzie [hl7:name/@code='KDLEK']

hl7:name CV 1 … 1 M (plCnse)

@code CONF 1 … 1 F KDLEK

@codeSystem 1 … 1 F 2.16.840.1.113883.3.4424.13.5.1

@codeSystemName 1 … 1 F PolskieKlasyfikatoryHL7v3

@displayName 1 … 1 F Kategoria dostępności leku

hl7:value CD 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.75 Kategoria dostępności leku w dokumencie realizacji recepty (DYNAMICZNE)

hl7:qualifier CR 1 … 1 M (plCnse)

gdzie [hl7:name/@code='RLEK']

hl7:name CV 1 … 1 M (plCnse)

@code CONF 1 … 1 F RLEK

@codeSystem 1 … 1 F 2.16.840.1.113883.3.4424.13.5.1

@codeSystemName 1 … 1 F PolskieKlasyfikatoryHL7v3

@displayName 1 … 1 F Rodzaj leku

hl7:value CD 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.5 Rodzaj leku (DYNAMICZNE)

hl7:qualifier CR 1 … 1 M (plCnse)

gdzie [hl7:name/@code='TWREC']

hl7:name CV 1 … 1 M (plCnse)

@code CONF 1 … 1 F TWREC

@codeSystem 1 … 1 F 2.16.840.1.113883.3.4424.13.5.1

@codeSystemName 1 … 1 F PolskieKlasyfikatoryHL7v3

@displayName 1 … 1 F Tryb wystawienia recepty

hl7:value CD 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.7 Tryb wystawienia recepty (DYNAMICZNE)

hl7:qualifier CR 1 … 1 M (plCnse)

gdzie [hl7:name/@code='TRREC']

hl7:name CV 1 … 1 M (plCnse)

@code CONF 1 … 1 F TRREC

@codeSystem 1 … 1 F 2.16.840.1.113883.3.4424.13.5.1

@codeSystemName 1 … 1 F PolskieKlasyfikatoryHL7v3

@displayName 1 … 1 F Tryb realizacji recepty

hl7:value CD 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.8 Tryb realizacji recepty (DYNAMICZNE)

hl7:qualifier CR 1 … 1 M (plCnse)

gdzie [hl7:name/@code='RRREC']

hl7:name CV 1 … 1 M (plCnse)

@code CONF 1 … 1 F RRREC

@codeSystem 1 … 1 F 2.16.840.1.113883.3.4424.13.5.1

@codeSystemName 1 … 1 F PolskieKlasyfikatoryHL7v3

@displayName 1 … 1 F Rodzaj realizacji recepty

hl7:value CD 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.76 Rodzaj realizacji recepty (DYNAMICZNE)

hl7:qualifier CR 1 … 1 M (plCnse)

gdzie [hl7:name/@code='PREC']

hl7:name CV 1 … 1 M (plCnse)

@code CONF 1 … 1 F PREC

@codeSystem 1 … 1 F 2.16.840.1.113883.3.4424.13.5.1

@codeSystemName 1 … 1 F PolskieKlasyfikatoryHL7v3

@displayName 1 … 1 F Postać recepty

hl7:value CD 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.77 Postać recepty (DYNAMICZNE)

hl7:qualifier CR 0 … 1 (plCnse)

gdzie [hl7:name/@code='RRECP']

hl7:name CV 1 … 1 M (plCnse)

@code CONF 1 … 1 F RRECP

@codeSystem 1 … 1 F 2.16.840.1.113883.3.4424.13.5.1

@codeSystemName 1 … 1 F PolskieKlasyfikatoryHL7v3

@displayName 1 … 1 F Rodzaj recepty papierowej

hl7:value CD 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.78 Rodzaj recepty papierowej (DYNAMICZNE)

hl7:qualifier CR 0 … 1 (plCnse)

gdzie [hl7:name/@code='RRECE']

hl7:name CV 1 … 1 M (plCnse)

@code CONF 1 … 1 F RRECE

@codeSystem 1 … 1 F 2.16.840.1.113883.3.4424.13.5.1

@codeSystemName 1 … 1 F PolskieKlasyfikatoryHL7v3

@displayName 1 … 1 F Rodzaj recepty elektronicznej

hl7:value CD 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.85 Rodzaj recepty elektronicznej (DYNAMICZNE)

hl7:qualifier CR 0 … 1 (plCnse)

gdzie [hl7:name/@code='TWLEK']

hl7:name CV 1 … 1 M (plCnse)

@code CONF 1 … 1 F TWLEK

@codeSystem 1 … 1 F 2.16.840.1.113883.3.4424.13.5.1

@codeSystemName 1 … 1 F PolskieKlasyfikatoryHL7v3

@displayName 1 … 1 F Tryb wydania leku

hl7:value CD 1 … 1 M (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.79 Tryb wydania leku (DYNAMICZNE)

hl7:title ST 1 … 1 M (plCnse)

Schematron assert rola error

test starts-with(hl7:title,'Realizacja recepty')

Komunikat Tytuł dokumentu musi się zaczynać od ciągu znaków: "Realizacja recepty".

hl7:effectiveTime TS 1 … 1 M (plCnse)

Schematron assert rola error

test concat(substring(@value,1,4),'-',substring(@value,5,2),'-',substring(@value,7,2)) castable as xs:date

Komunikat Pierwsze 8 cyfr daty powinno być w formacie YYYYMMDD.

hl7:confidentialityCode CE 1 … 1 M (plCnse)

@code CONF 1 … 1 F N

@codeSystem 1 … 1 F 2.16.840.1.113883.5.25

hl7:languageCode CS 1 … 1 M (plCnse)

@code CONF 1 … 1 F pl-PL

hl7:setId II 1 … 1 M (plCnse)

hl7:versionNumber INT 1 … 1 M (plCnse)

@value int 1 … 1 R

Dołączony 1 … 1 M z 2.16.840.1.113883.3.4424.13.10.2.88 [2] Dane pacjenta dla dokumentu realizacji recepty (DYNAMICZNE)

hl7:recordTarget 1 … 1 M (plCnse)

@typeCode 0 … 1 F RCT

@contextControlCode 0 … 1 F OP

hl7:templateId II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.88

hl7:patientRole

0 … 1

Ostrzeżenie: Jeśli isMandatory = true, minimumMultiplicity musi być większe od 0.

(plC

nse)

@classCode 0 … 1 F PAT

hl7:id II 1 … * M (plCnse)

@root uid 1 … 1 R

@extension st 1 … 1 R

Schematron report rola error

test @root='2.16.840.1.113883.3.4424.1.1.616' and not(matches(string(@extension),'^[0-9]{11}$'))

Komunikat Jeżeli identyfikatorem jest numer PESEL, to musi zawierać 11 cyfr.

Dołączony 0 … 1 R z 2.16.840.1.113883.3.4424.13.10.7.1 [7] Adres (bazowy) (DYNAMICZNE)

hl7:addr 0 … 1 R (plCnse)

@nullFlavor cs 0 … 1 F UNK

hl7:country ADXP 0 … 1 (plCnse)

hl7:postalCode 0 … 1 (plCnse)

@xsi:type 0 … 1 F extPL:adxp

@postCity st 0 … 1

hl7:city ADXP 0 … 1 (plCnse)

hl7:streetName ADXP 0 … 1 (plCnse)

hl7:houseNumber ADXP 0 … 1 (plCnse)

hl7:unitID ADXP 0 … 1 (plCnse)

hl7:unitType ADXP 0 … 1 (plCnse)

hl7:censusTract ADXP 0 … 1 (plCnse)

Schematron report rola error

test not(@nullFlavor) and ((not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:postalCode))

Komunikat Dla polskiego adresu wymagane jest podanie kodu pocztowego.

Schematron report rola error

test not(@nullFlavor) and (not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:city)

Komunikat Dla polskiego adresu wymagane jest podanie miasta.

Schematron report rola error

test not(@nullFlavor) and (not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:houseNumber)

Komunikat Dla polskiego adresu wymagane jest podanie numeru domu.

Schematron assert rola error

test not(hl7:censusTract) or starts-with(hl7:censusTract,'TERYT TERC:') or starts-with(hl7:censusTract,'TERYT SIMC:')

Komunikat Poprawnie zapisany numer TERYT powinien zaczynać się od znaków: "TERYT TERC:" lub "TERYT SIMC:".

Schematron report rola error

test @nullFlavor and count(./*) > 1

Komunikat Jeżeli adres jest nieznany, to nie może zawierać żadnych składników adresu.

hl7:telecom TEL 0 … 1 R (plCnse)

hl7:patient 0 … 1 (plCnse)

@classCode 0 … 1 F PSN

@determinerCode 0 … 1 F INSTANCE

hl7:id II 0 … * NP (plCnse)

Dołączony 0 … 1 R z 2.16.840.1.113883.3.4424.13.10.7.2 [7] Nazwisko i imię osoby (bazowy) (DYNAMICZNE)

hl7:name 0 … 1 R (plCnse)

hl7:prefix ENXP 0 … 1 (plCnse)

hl7:given ENXP 1 … * R (plCnse)

hl7:family ENXP 1 … * R (plCnse)

hl7:administrativeGenderCode CE 0 … 1 (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.1.11.1 AdministrativeGender (DYNAMICZNE)

hl7:birthTime TS.DATE 0 … 1 R (plCnse)

Schematron assert rola error

test concat(substring(@value,1,4),'-',substring(@value,5,2),'-',substring(@value,7,2)) castable as xs:date

Komunikat Pierwsze 8 cyfr daty urodzenia powinno być w formacie YYYYMMDD.

hl7:guardian 0 … * (plCnse)

@classCode 1 … 1 F GUARD

hl7:id II 1 … * (plCnse)

@root uid 1 … 1 R

@extension st 1 … 1 R

Schematron report rola error

test @root='2.16.840.1.113883.3.4424.1.1.616' and not(matches(string(@extension),'^[0-9]{11}$'))

Komunikat Jeżeli identyfikatorem jest numer PESEL to musi zawierać 11 cyfr.

hl7:code CE 0 … 1 (plCnse)

@codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.111

Dołączony 0 … 1 z 2.16.840.1.113883.3.4424.13.10.7.1 [7] Adres (bazowy) (DYNAMICZNE)

hl7:addr 0 … 1 (plCnse)

@nullFlavor cs 0 … 1 F UNK

hl7:country ADXP 0 … 1 (plCnse)

hl7:postalCode 0 … 1 (plCnse)

@xsi:type 0 … 1 F extPL:adxp

@postCity st 0 … 1

hl7:city ADXP 0 … 1 (plCnse)

hl7:streetName ADXP 0 … 1 (plCnse)

hl7:houseNumber ADXP 0 … 1 (plCnse)

hl7:unitID ADXP 0 … 1 (plCnse)

hl7:unitType ADXP 0 … 1 (plCnse)

hl7:censusTract ADXP 0 … 1 (plCnse)

Schematron report rola error

test not(@nullFlavor) and ((not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:postalCode))

Komunikat Dla polskiego adresu wymagane jest podanie kodu pocztowego.

Schematron report rola error

test not(@nullFlavor) and (not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:city)

Komunikat Dla polskiego adresu wymagane jest podanie miasta.

Schematron report rola error

test not(@nullFlavor) and (not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:houseNumber)

Komunikat Dla polskiego adresu wymagane jest podanie numeru domu.

Schematron assert rola error

test not(hl7:censusTract) or starts-with(hl7:censusTract,'TERYT TERC:') or starts-with(hl7:censusTract,'TERYT SIMC:')

Komunikat Poprawnie zapisany numer TERYT powinien zaczynać się od znaków: "TERYT TERC:" lub "TERYT SIMC:".

Schematron report rola error

test @nullFlavor and count(./*) > 1

Komunikat Jeżeli adres jest nieznany, to nie może zawierać żadnych składników adresu.

Wybór

1 … 1

Elementy do wyboru z:

hl7:guardianPerson zawierający szablon2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE)
hl7:guardianOrganization zawierający szablon2.16.840.1.113883.3.4424.13.10.2.2 [2] Organizacja (bazowy) (DYNAMICZNE)

hl7:guardianPerson Zawiera 2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) (plCnse)

gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.1']]

hl7:guardianOrganization Zawiera 2.16.840.1.113883.3.4424.13.10.2.2 [2] Organizacja (bazowy) (DYNAMICZNE) (plCnse)

gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.2']]

extPL:multipleBirthInd BL 0 … 1 (plCnse)

extPL:multipleBirthOrderNumber INT.POS 0 … 1 (plCnse)

Schematron report rola error

test extPL:multipleBirthInd/@value and not(extPL:multipleBirthOrderNumber/@value)

Komunikat Dla ciąży mnogiej wymagane jest podanie numeru kolejności urodzenia.

hl7:providerOrganization 0 … 1 Zawiera 2.16.840.1.113883.3.4424.13.10.2.2 [2] Organizacja (bazowy) (DYNAMICZNE) (plCnse)

gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.2']]

Schematron report rola error

test /hl7:ClinicalDocument[hl7:code[hl7:translation[hl7:qualifier[hl7:name/@code='PREC' and hl7:value/@code='E']]]] and not(hl7:addr[not(@nullFlavor)] and hl7:patient[hl7:name[not(@nullFlavor)] and hl7:birthTime[not(@nullFlavor)]])

Komunikat Dla dokumentu realizacji recepty elektronicznej wymagane jest podanie imienia i nazwiska pacjenta, jego adresu oraz daty urodzenia.

Dołączony 1 … 1 M z 2.16.840.1.113883.3.4424.13.10.2.84 [2] Autor dokumentu realizacji recepty (DYNAMICZNE)

hl7:author 1 … 1 M (plCnse)

@typeCode 0 … 1 F AUT

@contextControlCode 0 … 1 F OP

hl7:templateId II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.84

hl7:functionCode CE 1 … 1 R (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.3.4424.13.11.23 Zawód medyczny uprawniony do wystawiania dokumentu realizacji recepty (DYNAMICZNE)

hl7:time TS 1 … 1 M (plCnse)

Schematron assert rola error

test (@value=/hl7:ClinicalDocument/hl7:legalAuthenticator/hl7:time/@value) or (@value=/hl7:ClinicalDocument/hl7:authenticator/hl7:time/@value)

Komunikat Data utworzenia dokumentu powinna być taka sama jak data wystawienia lub autoryzacji dokumentu.

hl7:assignedAuthor 1 … 1 R (plCnse)

@classCode 0 … 1 F ASSIGNED

Wybór

1 … 1

Elementy do wyboru z:

hl7:id[@root='2.16.840.1.113883.3.4424.1.6.1']
hl7:id[@root='2.16.840.1.113883.3.4424.1.1.616']

hl7:id II 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.1.6.1']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.1.6.1

@extension st 1 … 1 R

hl7:id II 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.1.1.616']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.1.1.616

@extension st 1 … 1 R

Schematron report rola error

test @root='2.16.840.1.113883.3.4424.1.1.616' and not(matches(string(@extension),'^[0-9]{11}$'))

Komunikat Jeżeli identyfikatorem jest numer PESEL, to musi zawierać 11 cyfr.

hl7:addr AD 0 … * (plCnse)

hl7:telecom TEL 0 … * (plCnse)

hl7:assignedPerson 1 … 1 Zawiera 2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) (plCnse)

gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.1']]

hl7:representedOrganization 0 … 1 Zawiera 2.16.840.1.113883.3.4424.13.10.2.31 [2] Apteka (bazowy) (DYNAMICZNE) (plCnse)

gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.31']]

Dołączony 0 … 1 z 2.16.840.1.113883.3.4424.13.10.2.44 [2] Dane umowy związanej z refundacją (DYNAMICZNE)

extPL:boundedBy 0 … 1 (plCnse)

@typeCode cs 1 … 1 F PART

extPL:templateId II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.44

extPL:reimbursementRelatedContract 1 … 1 M (plCnse)

@classCode cs 1 … 1 F CNTRCT

@moodCode cs 1 … 1 F EVN

Wybór

1 … 1

Elementy do wyboru z:

extPL:id[@nullFlavor='NA']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.1']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.2']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.3']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.4']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.5']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.6']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.7']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.8']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.9']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.10']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.11']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.12']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.13']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.14']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.15']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.1.16']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.1']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.2']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.3']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.4']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.5']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.6']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.7']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.8']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.9']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.10']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.11']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.12']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.13']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.14']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.15']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.2.16']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.1']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.2']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.3']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.4']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.5']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.6']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.7']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.8']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.9']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.10']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.11']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.12']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.13']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.14']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.15']
extPL:id[@root='2.16.840.1.113883.3.4424.8.6.3.16']

extPL:id 0 … 1 (plCnse)

gdzie [@nullFlavor='NA']

@nullFlavor cs 1 … 1 F NA

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.1']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.1

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.2']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.2

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.3']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.3

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.4']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.4

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.5']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.5

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.6']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.6

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.7']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.7

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.8']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.8

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.9']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.9

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.10']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.10

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.11']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.11

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.12']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.12

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.13']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.13

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.14']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.14

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.15']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.15

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.1.16']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.1.16

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.1']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.1

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.2']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.2

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.3']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.3

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.4']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.4

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.5']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.5

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.6']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.6

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.7']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.7

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.8']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.8

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.9']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.9

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.10']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.10

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.11']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.11

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.12']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.12

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.13']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.13

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.14']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.14

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.15']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.15

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.2.16']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.2.16

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.1']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.1

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.2']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.2

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.3']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.3

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.4']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.4

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.5']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.5

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.6']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.6

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.7']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.7

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.8']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.8

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.9']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.9

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.10']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.10

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.11']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.11

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.12']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.12

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.13']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.13

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.14']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.14

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.15']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.15

@extension st 1 … 1 R

extPL:id 0 … 1 (plCnse)

gdzie [@root='2.16.840.1.113883.3.4424.8.6.3.16']

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.8.6.3.16

@extension st 1 … 1 R

extPL:code 0 … 1 (plCnse)

extPL:bounding 1 … 1 M (plCnse)

@typeCode cs 1 … 1 F PART

extPL:reimburser 1 … 1 M (plCnse)

@classCode cs 1 … 1 F UNDWRT

extPL:id II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.3.1

@extension st 1 … 1 R

Schematron report rola error

test (hl7:assignedAuthor/hl7:id/@root='2.16.840.1.113883.3.4424.1.6.1' and not(hl7:functionCode/@code='FARM')) or (hl7:assignedAuthor/hl7:id/@root='2.16.840.1.113883.3.4424.1.1.616' and not(hl7:functionCode/@code='TFARM'))

Komunikat Wskazana pula numerów Prawa Wykonywania Zawodu jest nieprawidłowa w stosunku do wskazanego zawodu autora dokumentu

hl7:dataEnterer NP (plCnse)

hl7:informant NP (plCnse)

Dołączony 1 … 1 M z 2.16.840.1.113883.3.4424.13.10.2.20 [2] Organizacja odpowiedzialna za dokument dla P1 (DYNAMICZNE)

hl7:custodian 1 … 1 M (plCnse)

@typeCode 0 … 1 F CST

hl7:templateId II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.20

hl7:assignedCustodian 1 … 1 M (plCnse)

@classCode 0 … 1 F ASSIGNED

hl7:representedCustodianOrganization 1 … 1 M (plCnse)

@classCode 0 … 1 F ORG

@determinerCode 0 … 1 F INSTANCE

hl7:id II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424

@extension st 0 NP NP/nie występuje

@assigningAuthorityName st 1 … 1 F CSIOZ

@displayable bl 1 … 1 R

hl7:name ON 0 … * NP (plCnse)

hl7:telecom TEL 0 … * NP (plCnse)

hl7:addr AD 0 … * NP (plCnse)

Dołączony 0 … * z 2.16.840.1.113883.3.4424.13.10.2.61 [2] Odbiorca informacji (bazowy) (DYNAMICZNE)

hl7:informationRecipient 0 … * (plCnse)

@typeCode cs 1 … 1 R

CONF

Wartość @typeCode musi pochodzić ze zbioru wartości 2.16.840.1.113883.1.11.19366 x_InformationRecipient (DYNAMICZNE)

hl7:templateId II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.61

hl7:intendedRecipient 1 … 1 (plCnse)

@classCode cs 1 … 1 R

CONF

@classCode musi mieć wartość "ASSIGNED"

hl7:id II 0 … * R (plCnse)

Dołączony 0 … * z 2.16.840.1.113883.3.4424.13.10.7.1 [7] Adres (bazowy) (DYNAMICZNE)

hl7:addr 0 … * (plCnse)

@nullFlavor cs 0 … 1 F UNK

hl7:country ADXP 0 … 1 (plCnse)

hl7:postalCode 0 … 1 (plCnse)

@xsi:type 0 … 1 F extPL:adxp

@postCity st 0 … 1

hl7:city ADXP 0 … 1 (plCnse)

hl7:streetName ADXP 0 … 1 (plCnse)

hl7:houseNumber ADXP 0 … 1 (plCnse)

hl7:unitID ADXP 0 … 1 (plCnse)

hl7:unitType ADXP 0 … 1 (plCnse)

hl7:censusTract ADXP 0 … 1 (plCnse)

Schematron report rola error

test not(@nullFlavor) and ((not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:postalCode))

Komunikat Dla polskiego adresu wymagane jest podanie kodu pocztowego.

Schematron report rola error

test not(@nullFlavor) and (not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:city)

Komunikat Dla polskiego adresu wymagane jest podanie miasta.

Schematron report rola error

test not(@nullFlavor) and (not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:houseNumber)

Komunikat Dla polskiego adresu wymagane jest podanie numeru domu.

Schematron assert rola error

test not(hl7:censusTract) or starts-with(hl7:censusTract,'TERYT TERC:') or starts-with(hl7:censusTract,'TERYT SIMC:')

Komunikat Poprawnie zapisany numer TERYT powinien zaczynać się od znaków: "TERYT TERC:" lub "TERYT SIMC:".

Schematron report rola error

test @nullFlavor and count(./*) > 1

Komunikat Jeżeli adres jest nieznany, to nie może zawierać żadnych składników adresu.

hl7:telecom TEL 0 … * (plCnse)

hl7:informationRecipient 0 … 1 Zawiera 2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) (plCnse)

gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.1']]

hl7:receivedOrganization 1 … 1 R Zawiera 2.16.840.1.113883.3.4424.13.10.2.89 [2] Organizacja do której kierowany jest dokument (DYNAMICZNE) (plCnse)

gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.89']]

Dołączony 1 … 1 M z 2.16.840.1.113883.3.4424.13.10.2.6 [2] Wystawca dokumentu (bazowy) (DYNAMICZNE)

hl7:legalAuthenticator 1 … 1 M (plCnse)

@typeCode 0 … 1 F LA

@contextControlCode 0 … 1 F OP

hl7:templateId II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.6

hl7:time TS 1 … 1 R (plCnse)

hl7:signatureCode CS 1 … 1 R (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.1.11.10282 ParticipationSignature (DYNAMICZNE)

hl7:assignedEntity 1 … 1 M (plCnse)

@classCode 0 … 1 F ASSIGNED

hl7:id II 1 … * M (plCnse)

@root uid 1 … 1 R

@extension st 1 … 1 R

hl7:code CE 0 … 1 (plCnse)

Dołączony 0 … * z 2.16.840.1.113883.3.4424.13.10.7.1 [7] Adres (bazowy) (DYNAMICZNE)

hl7:addr 0 … * (plCnse)

@nullFlavor cs 0 … 1 F UNK

hl7:country ADXP 0 … 1 (plCnse)

hl7:postalCode 0 … 1 (plCnse)

@xsi:type 0 … 1 F extPL:adxp

@postCity st 0 … 1

hl7:city ADXP 0 … 1 (plCnse)

hl7:streetName ADXP 0 … 1 (plCnse)

hl7:houseNumber ADXP 0 … 1 (plCnse)

hl7:unitID ADXP 0 … 1 (plCnse)

hl7:unitType ADXP 0 … 1 (plCnse)

hl7:censusTract ADXP 0 … 1 (plCnse)

Schematron report rola error

test not(@nullFlavor) and ((not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:postalCode))

Komunikat Dla polskiego adresu wymagane jest podanie kodu pocztowego.

Schematron report rola error

test not(@nullFlavor) and (not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:city)

Komunikat Dla polskiego adresu wymagane jest podanie miasta.

Schematron report rola error

test not(@nullFlavor) and (not(hl7:country) or upper-case(hl7:country)='POLSKA') and not(hl7:houseNumber)

Komunikat Dla polskiego adresu wymagane jest podanie numeru domu.

Schematron assert rola error

test not(hl7:censusTract) or starts-with(hl7:censusTract,'TERYT TERC:') or starts-with(hl7:censusTract,'TERYT SIMC:')

Komunikat Poprawnie zapisany numer TERYT powinien zaczynać się od znaków: "TERYT TERC:" lub "TERYT SIMC:".

Schematron report rola error

test @nullFlavor and count(./*) > 1

Komunikat Jeżeli adres jest nieznany, to nie może zawierać żadnych składników adresu.

hl7:telecom TEL 0 … * (plCnse)

hl7:assignedPerson 0 … 1 Zawiera 2.16.840.1.113883.3.4424.13.10.2.1 [2] Osoba (bazowy) (DYNAMICZNE) (plCnse)

gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.1']]

hl7:representedOrganization 0 … 1 Zawiera 2.16.840.1.113883.3.4424.13.10.2.2 [2] Organizacja (bazowy) (DYNAMICZNE) (plCnse)

gdzie [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.2.2']]

Schematron report rola error

test not(hl7:assignedPerson/hl7:name) and not(hl7:id[@root=/hl7:ClinicalDocument/hl7:author/hl7:assignedAuthor/hl7:id/@root and @extension=/hl7:ClinicalDocument/hl7:author/hl7:assignedAuthor/hl7:id/@extension])

Komunikat Jeśli wystawca dokumentu jest również jego autorem to identyfikator wystawcy musi być taki sam jak identyfikator autora. W przeciwnym wypadku należy podać dane personalne wystawcy dokumentu.

hl7:authenticator NP (plCnse)

Dołączony 0 … * z 2.16.840.1.113883.3.4424.13.10.2.53 [2] Dane zlecenia (bazowy) (DYNAMICZNE)

hl7:inFulfillmentOf 0 … * (plCnse)

@typeCode 0 … 1 F FLFS

hl7:templateId II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.53

hl7:order 1 … 1 (plCnse)

@classCode 0 … 1 F ACT

@moodCode 1 … 1 F RQO

hl7:id II 1 … * M (plCnse)

hl7:code CE 0 … 1 (plCnse)

@codeSystem CONF 0 … 1 F 2.16.840.1.113883.5.4 (ActCode)

hl7:priorityCode CE 0 … 1 (plCnse)

CONF

Wartość @code musi pochodzić ze zbioru wartości 2.16.840.1.113883.1.11.16866 ActPriority (DYNAMICZNE)

hl7:documentationOf NP (plCnse)

Dołączony 0 … 1 z 2.16.840.1.113883.3.4424.13.10.2.83 [2] Dokument powiązany dla dokumentu recepty (DYNAMICZNE)

hl7:relatedDocument 0 … 1 (plCnse)

@typeCode cs 1 … 1 F RPLC

hl7:templateId II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.83

hl7:parentDocument 1 … 1 R (plCnse)

@classCode 0 … 1 F DOCCLIN

@moodCode 0 … 1 F EVN

hl7:id II 1 … 1 M (plCnse)

hl7:setId II 1 … 1 M (plCnse)

hl7:versionNumber INT 1 … 1 M (plCnse)

Schematron report rola error

test hl7:id[@root=/hl7:ClinicalDocument/hl7:id/@root and @extension=/hl7:ClinicalDocument/hl7:id/@extension]

Komunikat Idetyfikator dokumentu jest taki sam jak identyfikator dokumentu powiązanego wskazujcego na jego poprzednią wersję.

Schematron assert rola error

test hl7:setId[@root=/hl7:ClinicalDocument/hl7:setId/@root and @extension=/hl7:ClinicalDocument/hl7:setId/@extension]

Komunikat Identyfikator grupy wersji dokumentów (setId) powienien być identyczny dla dokumentu i dokumentu powiązanego wskazującego na jego poprzednią wersję.

Schematron assert rola error

test (xs:integer(hl7:versionNumber/@value)+1)=xs:integer(/hl7:ClinicalDocument/hl7:versionNumber/@value)

Komunikat Dokument powiązany powienien wskazywać poprzednią wersję dokumentu.

hl7:authorization NP (plCnse)

hl7:componentOf NP (plCnse)

Dołączony 1 … 1 M z 2.16.840.1.113883.3.4424.13.10.2.80 [2] Treść dokumentu realizacji recepty (DYNAMICZNE)

hl7:component 1 … 1 M (plCnse)

@typeCode 0 … 1 F COMP

@contextConductionInd bl 0 … 1

hl7:templateId II 1 … 1 M (plCnse)

@root uid 1 … 1 F 2.16.840.1.113883.3.4424.13.10.2.80

hl7:structuredBody 1 … 1 M (plCnse)

@classCode 0 … 1 F DOCBODY

@moodCode 0 … 1 F EVN

hl7:component 1 … 1 M Zawiera 2.16.840.1.113883.3.4424.13.10.3.70 [3] Sekcja wydania leku (DYNAMICZNE) (plCnse)

gdzie [hl7:section [hl7:code [(@code='60590-7' and @codeSystem='2.16.840.1.113883.6.1')]]]

hl7:component 0 … 1 R Zawiera 2.16.840.1.113883.3.4424.13.10.3.69 [3] Sekcja danych ubezpieczeniowych (DYNAMICZNE) (plCnse)

gdzie [hl7:section [hl7:code [(@code='48768-6' and @codeSystem='2.16.840.1.113883.6.1')]]]

hl7:component 0 … 1 Zawiera 2.16.840.1.113883.3.4424.13.10.3.2 [3] Sekcja informacji dodatkowych (DYNAMICZNE) (plCnse)

gdzie [hl7:section [hl7:templateId [@root='2.16.840.1.113883.3.4424.13.10.3.2']]]

Schematron report rola error

test //hl7:act[hl7:templateId/@root='2.16.840.1.113883.3.4424.13.10.4.67']/hl7:entryRelationship/hl7:observation[hl7:code/@code='RLPO']/hl7:value/@code!='100%' and not(hl7:component/hl7:section[hl7:templateId[@root='2.16.840.1.113883.3.4424.13.10.3.69']])

Komunikat Dla realizacji recepty refundowanej wymagana jest sekcja danych ubezpieczeniowych

Zmienna let Nazwa versionLabel

Wartość '1.3.1'

Schematron report rola error

test hl7:code/hl7:translation/hl7:qualifier[hl7:name/@code='PREC']/hl7:value/@code='P' and not(hl7:code/hl7:translation/hl7:qualifier[hl7:name/@code='RRECP'])

Komunikat Dokument realizacji recepty papierowej musi zawierać informacje o rodzaju recepty papierowej.

Schematron assert rola error

test count(hl7:templateId[@root and xs:string(@extension)=xs:string($versionLabel)])=1

Komunikat Nie występuje prawidłowe oznaczenie zgodności dokumentu z daną wersją wydania Polskiej Implementacji Krajowej HL7 CDA.

Schematron assert rola error

test /processing-instruction('xml-stylesheet') = concat('href="CDA_PL_IG_',$versionLabel,'.xsl" type="text/xsl"')

Komunikat Nieprawidłowe wskazanie transformaty generującej warstwę prezentacyjną dokumentu.

Szablon [1] Realizacja recepty